An ongoing dialogue on HIV/AIDS, infectious diseases, all matters medical, and some not so medical.

August 20th, 2017

Two Quick Thoughts Inspired by Inpatient ID Consults, and An Inspirational Baseball Poster

Mount Ararat, original source of daptomycin.

A couple of quick thoughts for those of us doing inpatient care these days:

Thought One: Is daptomycin now preferred over vancomycin in most clinical settings?

It’s taken a while, but we’re getting there — close to that Gladwelllian “tipping point”. Allow this recap of vancomycin’s problems:

The growing recognition that higher drug levels — the levels we want — bring with them more side effects.

The extraordinary hassle and imprecision of monitoring vancomycin levels.

The enormous variability in dosing due to differences in clearance from patient-to-patient.

The lengthy vancomycin infusion time (at least 60 minutes/dose) which, if you have a patient on every 8 hour dosing, means they are spending many of their waking hours receiving vancomycin.

If you add to these issues the substantial decrease in daptomycin’s cost since it went generic, it’s hard to justify using vancomycin over daptomycin for many non-pneumonia indications these days.

Daptomycin is far from perfect, but if it replaces vancomycin there will be few tears shed on its behalf — vancomycin isn’t such a great drug either. Beta lactams are preferred over both of them for susceptible organisms.

And for the next time there’s a lull in the conversation with your friends, here are some fun facts about daptomycin, including how it was discovered on Mount Ararat in Turkey.

Two recent studies highlight the hazards associated with sending patients out of the hospital with intravenous lines to complete antibiotic therapy:

Out of 339 patients prospectively studied from two academic medical centers, 18% experienced a significant adverse drug event, most commonly during the first two weeks after discharge. Note that most retrospective analyses have even higher rates, probably because many are discharged without being in an organized OPAT program.

In people who inject drugs — a particularly challenging patient population who increasingly have “indications” for OPAT — a whopping 61% failed their OPAT course.

Aside from the medical challenges of OPAT, there’s also the clinical service side — which is dismal. Since payers typically do not reimburse providers for monitoring OPAT, this gives us ID doctors two terrible choices — provide the service for free because it’s good for patients or, alternatively, refuse to do it and document (leverage) the suboptimal care to get institutional funding.

The former is an example of our being “too nice”; the latter just makes me uncomfortable, but is increasingly required.

Bottom line: we should strive to give oral over IV antibiotics at discharge for all patients, except when the data strongly support parenteral therapy. Oral treatment is safer, cheaper, and usually just as effective.

Finally, given the current political climate, isn’t this poster just awesome?

It’s a subway poster from 1950, published by the Institute for American Democracy.

The ADE rate is not too surprising; I spend a lot of time juggling OPAT meds due to rashes, neutropenia, etc. Another reason to look for oral options when appropriate. Like daptomycin, linezolid has had a large drop in price, and I wonder if it won’t replace some of the vancomycin we use, at least for non-bacteremic infections.

While well-organized OPAT programs con contribute greatly to patient care, there is an element of “if you build it, they will come.” (That’s as close as I will ever get to talking about baseball in an ID blog.) OPAT can be a profit center in some practices, and is sometimes overused because it’s available. One of our roles as antimicrobial stewards is to avert unnecessary IV therapy. There is debate over when it’s needed, but it sometimes is used in situations where no data support an advantage of IV therapy.

Finally, as a Jersey Boy, I wish to point out, with all due respect to Mount Ararat, that it was in New Jersey where streptomycin was identified and isolated, ushering in the modern antibiotic era.

In Australia, OPAT is reimbursed as for inpatient care (hence “hospital in the home”), and allows sufficient nursing staff to attend the patient up to twice per day.

HITH is perfect for stable patients that sit around getting bored while waiting for their occasional dose of antibiotics – osteomyelitis, the last few weeks of endocarditis, cellulitis. This service is also good for other patients that have subacute nursing requirements – complex dressings in the elderly, bridging anticoagulation – and at our hospital the HITH service is equivalent to 2-3 wards of patients.

Clearly, there may be some tendency to overtreatment, but with the right selection criteria we think it is a useful option for patients. Most HITH services have exclusions for patients using intravenous drugs for the reasons cited. We do worry somewhat about the balance between using suboptimal antibiotics (eg ceftriaxone, ertapenem) solely for frequency of dosing.

I like that reimbursement policy! In the USA, the payment is solely to the home care company/pharmacy, and the MDs or nurses overseeing and monitoring the OPAT get nothing. With Medicare (the government-funded insurance for the elderly) it’s even worse — home IV antibiotics are not covered at all!

Hello Paul ,this might be generalizing.In Houston we have several efficent and profitable OPAT centers run by Physicians ( such as our group),where the patient is very closely monitored.Moreover Medicare covers the home antibiotics but not the supplies needed, which i suppose is the same thing.
But if they make it once a day to the infusion center,depending on the antibiotics,theyre good.
IVDAs i understand can be very difficult,but the same dosent apply to insured compliant patients.
I hope the IDSA dosent guideline away against OPAT based on one size fits all.

Your blog provides clinicians and patients with accurate and current information about HIV and ID and combats the stigma and confusion that so often surround these issues. That’s why we’ve selected you to participate and help spread the love to an even wider audience.